Multidrug-Resistant Organism (MDRO)and

Clostridium difficile-Associated Disease (CDAD) Module

Katherine Allen-Bridson, RN, BSN, CICDivision of Healthcare Quality PromotionCenters for Disease Control and Prevention

Background

First Tier: General Recommendations For All Acute Care Settings

Second Tier: Intensified Interventionse.g., chlorhexidine washes, active surveillance testing for MRSA

If endemic rates not decreasing, orif first case of important organism

What Metrics?

HICPAC Guidance On Management of MDROs in

Healthcare Settings (8/10/2006)

SHEA/HICPAC Position Paper (October 2008): Recommendations for MDRO Metrics

in Healthcare Settings

Define reasonable and practical metrics to best measure impact of prevention

Authors from APIC, CDC, SHEA, HICPAC

Five Categories of MDRO Outcome Measures1.

Tracking Patients2.

Monitoring Susceptibility Patterns3.

Estimating Infection Burden4.

Estimating Exposure Burden5.

Quantifying Healthcare Acquisition (which includes Transmission)

Recommended metricsfrom the

SHEA/HICPAC Position Paperwere the basis

for thenew MDRO and CDAD Module

Module Overview

National Healthcare Safety Network (NHSN)

Patient SafetyComponent

Device-Associated

Module

Medication-Associated

Module

MDROand

CDADModule

Procedure-Associated

Module

High-RiskInpatient InfluenzaVaccination Module

Goal of the MDRO and CDAD Module

Monitoring of MDRO and C. difficile infection (CDI) helps to evaluate local trends and changes in the occurrence of these pathogens and related infections.

This module provides a mechanism for facilities to report and analyze MDRO and CDI data, in order to inform infection control staff of the impact of targeted prevention efforts.

Organisms Monitored1) Methicillin-Resistant Staphylococcus aureus (MRSA)

(option w/ Methicillin-Sensitive S. aureus (MSSA)

2) Vancomycin-Resistant Enterococcus spp. (VRE)

3) Multidrug-Resistant (MDR) Klebsiella spp.

4) Multidrug-Resistant (MDR) Acinetobacter spp.

5) Clostridium difficile-Associated Disease (CDAD)

MDRO and C. difficile Current Definitions

MRSA: S. aureus testing oxacillin resistant;or positive from molecular testing for mecA and PBP2a

MSSA: S. aureus testing oxacillin intermediate or susceptible; or(option)

negative from molecular testing for mecA and PBP2a

VRE: Any Enterococcus spp. testing resistant to vancomycin

MDR-Klebsiella: Klebsiella spp. testing intermediate or resistant to ceftazidime or ceftriaxone

MDR-Acinetobacter: Acinetobacter spp. resistant to all agents tested within at least 3 antimicrobial classes, including -lactams, carbapenems aminoglycosides, and fluoroquinolones

C. difficile: Gastrointestinal System Infection-Gastroenteritis or Gastrointestinal System Infection-Gastrointestinal Tract where C. difficile is the associated pathogen

MRSA: S. aureus testing oxacillin resistant; or(positive from molecular testing for mecA and PBP2a)

MSSA: S. aureus testing oxacillin intermediate or susceptible; or(negative from molecular testing for mecA and PBP2a)

VRE: Any Enterococcus spp. testing resistant to vancomycin

MDR-Klebsiella: Klebsiella spp. testing intermediate or resistant to ceftazidime or cefotaxime/ceftriaxone or cefepime

MDR-Acinetobacter: Acinetobacter spp. testing intermediate or resistant to at least one agent within at least 3 antimicrobial classes of 6,

including: penicillins, carbapenems, aminoglycosides, cephalosporins, quinolones, or sulbactam

C. difficile: C. difficile is identified as the associated pathogen forGastrointestinal System Infection-Gastroenteritis or Gastrointestinal System Infection-Gastrointestinal Tract

MDRO and C. difficile Definitions for 2011

Reporting Requirements and OptionsActive participants must choose main reporting method

Infection Surveillance LabID Event Reporting

additional options then become available

Prevention Process Measures:• Adherence to Hand Hygiene• Adherence to Gown and Glove Use• Adherence to Active Surveillance Testing

Outcome Measures:• AST Prevalence / Incidence

Reporting MethodsLocation Specific:-

Select only a few locations or full facility coverage.

-

Report separately from each selected location in the facility.-

Separate denominators (patient days, admissions, encounters) for both locations.

Facility-Wide Inpatient or Facility Wide Outpatient:-

Options available only in the MDRO/CDAD Module and only for LabID Event reporting.

-

Report totals from throughout a facility’s inpatient or outpatient locations.-

Single denominators (either patient days and admissions for

FacWideIN , or encounters for FacWIDE OUT) for entire facility.

Monthly Reporting Plan for Lab ID Event

Enter both

for inpatient and outpatient facility wide

Infection Surveillance

Purpose: To collect MDRO or CDI data on NHSN-defined healthcare-associated infections (HAIs)

HAI: A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent or its toxin. There must be no evidence that the infection was present or incubating at the time of admission to the location.

Report for at least three months any time in a calendar year

Location specific reporting

Inpatient locations (where denominator data can be collected)

Infection Surveillance Analysis

MDRO/CDI Infection Incidence Density Rate

# of reported MDRO or CDI Infections = X 1000

# of Patient-Days

(stratified by time and location)

LabID Event ReportingPurpose: To calculate proxy measures of MDRO or CDI events,

exposures, healthcare acquisitions through monitoring and reporting data from positive clinical cultures.

LabID Event: A laboratory-identified event. First positive MDRO/CDI isolate collected for diagnosis/treatment for the patient in a location during a month. Only time a patient will have > 1 LabID Event reported for a location in a month is for bloods (MDRO) or stool (CDI), as these can be reported every 14 days.

Report for at least three consecutive

months in a calendar year

Location specific or Overall facility-wide reporting

Report all specimens or blood specimens only (for Facility-wide reporting)

Inpatient locations (no NICUs or Well Baby Nurseries for CDI) andOutpatient locations (no dialysis centers nor Well Baby Clinics)

Identifying an MDRO LabID Event (if Monitoring All

Specimens Only)

LabID Event (unique MDRO blood source)

NONot aLabIDEvent

YES MDROfrom blood≤

2 wks

YES

NONot aLabIDEvent

MDROSource= blood

NO

LabID Event (non-duplicate

isolate)

YES1st

incalendarmonth

MDRO isolate from any specimen

Begin Here

Categorization of LabID EventsNHSN Application Categorizes LabID Events as:

Community-Onset (CO): LabID Event collected as an outpatient or as an inpatient ≤

3 days after admission to the

facility (i.e., days 1 (admission), 2, or 3)

Healthcare Facility-Onset (HO): LabID Event specimen collected > 3 days after admission to the facility (i.e., on or after day 4)

Community-Onset Healthcare Facility Associated (CO- HCFA): LabID Event collected from a patient who was

discharged from the facility < 4 weeks prior to date stool specimen collected. * C diff only

LabID Event Reporting AnalysisSpecific Metrics Exposure Infection Acquisition

Admission Prevalence RateOverall Prevalence Rate

Bloodstream Infection Admission Prevalence RateBloodstream Infection Incidence or Incidence Density Rate

Overall MDRO Infection/Colonization Incidence or Incidence Density Rate

Location CDI Incidence RateFacility CDI Healthcare Facility-Onset Incidence RateFacility CDI Combined Incidence Rate

Infection Surveillance

LabID Events

LabID Events versus AST

LabID Event reporting

is ONLY for collecting and tracking positive cultures that are taken for “clinical”

purposes (i.e., for

diagnosis and treatment), which means NO active surveillance testing/cultures (AST/ASC) results are be included in this reporting of individual events.

Active Surveillance Testing (AST)

is for collecting and tracking positive cultures that are collected for surveillance purposes (e.g., nasal or rectal swabs) to identify patients that

are colonized with a specific organism (i.e., MRSA or VRE) at admission to a location and at discharge or transfer out of the location. The data are NOT collected on an individual basis, but instead are entered as aggregate counts.

Adherence to Prevention Process Measures

Required Minimum Reporting -

if chosen:

a) HH: at least 30 unannounced observations after HCW contact

with patient or objects near patientb) GG: at least 30 unannounced observations during HCW contact

with patient or objects near patient

c) AST: conducted on patient Admission or

Admission & Discharge for MRSA and/or VRE only on All or

those with No History

Report for at least one month in a calendar year

Location specific reporting (suggest same location as IS or LabID reporting)

Inpatient locations and Outpatient (for HH) locations

Process Measures Adherence Analysis

Adherence Rate to Process Measures

# Performed or Used = X 100

# Indicated or Eligible

AST Outcomes Measures

Purpose: To allow facilities to more accurately quantify exposure burden (prevalence) and/or healthcare acquisition (incidence) of MRSA and/or VRE

Report for at least one month in a calendar year

Location specific reporting:•

required same location where AST adherence is performed

•

suggest same location where Infection Surveillance or LabID Event reporting is conducted

Inpatient locations

AST Outcomes Measures Definitions

•

AST at Admission provides Prevalence data–

Known Positive •

Patient with documented MRSA or VRE colonization or infection in previous 12 months

–

Admission AST or Clinical Positive•

Patient with MRSA or VRE isolated from specimen collected on admission (≤

3 days)

•

AST at Discharge/Transfer provides Incidence data–

Patient with stay > 3 days–

No documented MRSA or VRE in previous 12 months or on admission (≤

3 days)–

MRSA or VRE isolated from specimen collected > 3 days after admission or at time of discharge/transfer

AST Outcome Measures Analysis

AST Incidence / Direct Acquisition

# of Discharge/Transfer AST and New Clinical Positives = X 1000

# of Patient-Days

AST Admission Prevalence

# of Admission AST/Clinical/Known Positives = X 100

# of Admissions

Analysis and Output

1) Generate a Dataset

Generation of a Data Set

is specific to User Login

2) Choose Output Options

3) Choose Reporting Option and Organism

4) Basic Run Options – Line Listing

5) Basic Run Options – Frequency Tables

6) Basic Run Options – Pie or Bar Charts

7) Basic Run Options – Rate Tables

Modify - Output Options

Modify – Line Listing

Modify – Rate Table

FYI: an “or”

command worksby using diagonal cells

Export ‘Analysis’ or ‘Output’ Data Set

“Export Analysis Data Set”: will export the data from the category through which you have navigated to get to the Modify screen.

“Export Output Data Set”: will export the data from the subset which you have specified on the Modify screen.

Export Data Set Facility Users Only

“Export Data”: will export all data in all categories ever entered for the facility.

NHSN Reference

Home Page:http://www.cdc.gov/nhsn

Questions